Download The Basics of Anesthesia Billing.

The Basics of Anesthesia
Billing.
Judy A. Wilson, CPC,CPC-H,CPC-P,CPC-I,CANPC,CMBSI,CMRS
Disclosures

This ppresentation is intended to provide
p
basic
educational information regarding
coding/billing for anesthesia and not intended
to convey coding advice and does not
represent the following:



Official policy of the ASA (American Society of
Anesthesiologists)
Official policy of the Virginia CMS
Every effort has been made to assure the
information in this presentation is accurate
1
Medicine’s Greatest Gift

Over one hundred fifty years ago, at Massachusetts
G
General
l Hospital,
H it l one off the
th greatest
t t moments
t in
i
medicine occurred. October 16, 1846 William T.G.
Morton, A Boston dentist, demonstrated the use of
ether during surgery, ending indescribable pain –
and the overwhelming dread – that had been
associated with the surgeon’s knife. Dr. Morton was
g a surgery,
g y, Dr.
not the first to use ether during
Crawford Williamson Long use it in 1842 to remove
a tumor. Because Long did not publish or publicize
his work, Dr. Morton usually gets credit for the
discovery of anesthesia.
Medicine’s Greatest Gift Continued

Dr. Morton used ether on a patient while extracting a
tooth. The patient was so impressed that they went
to the local newspaper. Dr. Morton was urged to
demonstrate the use of ether during an operation at
Massachusetts General Hospital. He used a specially
designed glass inhaler containing an ether-soaked
sponge to administer the anesthetic to the patient,
Gilbert Abbott, who was in the hospital clinic for
treatment of a vascular tumor on his jaw.
2
Medicine’s Greatest Gift Continued

After several minutes, the p
patient was unconscious.
The surgeon John Collins Warren MD, one of the
most widely recognized surgeons of the time,
surgically removed the tumor. The patient upon
wakening informed the curious and skeptical
physicians and medical students that he had
experienced
i
d NO PAIN.
PAIN D
Dr. W
Warren ttold
ld the
th
onlookers as they were taking the patient out,
“Gentlemen, this is no humbug.” A new era of
Medicine had begun.
How Does Anesthesia Work?

One of the most often asked question is how does
anesthesia
th i work?
k? The
Th question
ti is
i asked
k d in
i a way
that makes it clear that anesthesia is thought of as a
single entity, one medication or one technique. This
is a common misconception among patients.

While it seems impossible to believe that with
today’ss advanced scientific knowledge and
today
experimental techniques, it is true that the
mechanism of many medications used in anesthesia
are simply not clear.
3
Anesthesiology

Anesthesiology
gy is a practice
p
of medicine
specializing in:

The management of patients who are rendered
unconscious and/or insensible to pain and
emotional stress during surgical, obstetrical, and
certain other medical procedures
p
Anesthesiology (Cont)




The management
g
of problems
p
in pain
p relief
The management of cardiopulmonary
resuscitation
The management of problems in pulmonary care
The management of critically ill patients in
special care units
4
Types of Anesthesia


There are four broad categories of anesthesia that can be
used:
d
Local Anesthesia

Is the term used when injections of local anesthetic drugs are used
to block sensation to a very small and specific area of the body.
This usually involves the injections of anesthetic drug with a
needle. There are other ways of delivering local anesthetic drugsinjection is still the most common method of delivery. It works by
blocking nerve impulses. When the nerve is blocked it cannot
conduct an impulse and therefore no sensation can be
transmitted.
Type of Anesthesia

Regional
g
Anesthesia

Regional anesthesia involves the injection of local
anesthetic drugs in such a way that a large
number of nerves are blocked. This results in a
large region of the body without sensation. It is
similar to local anesthesia but has a larger
g effect.
(example: Epidurals for delivery)
5
Types of Anesthesia

MAC/Sedation

Can be accomplished with a variety of
medications. Most of the time, they are given
through an intravenous line directly into the
bloodstream. It is like a general on a smaller
level. Patient can usually
y answer qquestions and
follow direction given by the provider.
Types of Anesthesia

General

Renders the patient unconscious and unable to
respond to touch or questions.
6
Types of Anesthesia Providers


Anesthesiologist
Certified Register Nurse Anesthetist (CRNA)








Must accept assignment
May work without the oversight of an anesthesiologist
Anesthesiologist’s Assistant
Must accept assignment
May not work without the oversight of the
anesthesiologist
Resident
Never bill for
Student registered nurse anesthetist
Code Sets

Procedural coding
g





CPT® more than 60,000 codes
ASA RVG (Relative Value Guide) (adopted by Medicare
in 1987) about 300 codes
Anesthesia Crosswalk
Cross walks CPT® codes to Anesthesia codes
HIPAA requires the use of CPT® as the code set
 Which part


Anesthesia
Surgery
7
How Does Anesthesia Get Paid?



Base Units
+ Time Units
+ Modifying Units
National Anesthesia Conversion Factor




For Vi
F
Virginia
i i 2010
$20.99 per unit for Par Physician
$19.80 per unit for Non Par Physician
Effective June 1, 2010
8
Base Units

Sources





ASA Relative Value Guide
ASA Crosswalk
Others
Bill only the highest base unit procedure
Medicare Base units can be different than ASA
RVG; you should know what the base units are
for Medicare in your area because sometimes the
base unit will be higher than the ASA RVG.
Covered under the Base Units

A basic value is listed for anesthetic management of most
surgical
i l procedures.
d
This
Thi includes
i l d the
th value
l for
f all
ll usuall
anesthesia services except the time actually spent in
anesthesia care and any modifiers. The usual anesthesia
services included in the Basic Value include the usual preoperative and post-operative visits, the administration of
fluids and/or blood products incident to the anesthesia care
and interpretation of non-invasive monitoring (ECG,
temperature, blood
bl d pressure, etc.).
) Pl
Place off arterial,
i l centrall
venous and pulmonary artery catheters and use of
transesophageal echocardiography (TEE) are not included in
the basic unit values.
9
Start Time
Per Medicare Anesthesia Manual
 “Anesthesia time begins when the anesthesiologist
starts to prepare the patient for the procedure.
Normally, this service takes place in the operating
room, but in some cases, preparation may begin in
another location (i.e., holding area). Anesthesia time
is a continuous time period from the start of
anesthesia to the end of an anesthesia service.”
Start Time (Cont)

When the anesthesiologist
g starts preparing
p p
g the
patient for induction or when the patient is
under the care of an anesthesia provider

Present, refers to the anesthesia provider being in
constant contact with the patient
10
Start Time (Cont)


Show an action on the anesthesia record
indicating time
Must show documentation of activity on the
anesthesia record


Vital sign
Procedure
Start Time (Cont)


The time on the anesthesia record and the
time that is billed should match
The time on the doctor’s claim and the CRNA
claim should match
11
Anesthesia Time


You need to remember that if there is a break
in the anesthesia time you can not bill for that
time
Anesthesia provider can add blocks of time
around an interruption in anesthesia time as
l
long
as he
h is
i furnishing
f i hi continuous
ti
anesthesia
th i
care within the time periods around the
interruptions
Time Units


Never round times
Time increments

Medicare-fifteen minute units

Paid at one-tenth of a minute increment

Commercial insurance- other specified time units

Ten,
e , fifteen
tee or
o twelve
twe ve

Why use different units?

Usually paid in whole units. Rounded to the next unit
12
Stop Time

When the p
patient can be safelyy turned over to
a non-anesthesia provider

Never happens in the operating room
Discontinuous Time
Use when anesthesia is stopped
pp
e.g. Surgeon is delayed
 From Medicare Manual: “For services on or
after Jan. 01, 2000, the anesthesia provider
can add blocks of time around an interruption
in anesthesia time, as long as the anesthesia
provider is furnishing continuous anesthesia
care within the time periods around the
interruption.”

13
How to Document Discontinuous Time


Your anesthesia record should clearlyy show
when anesthesia time starts and stops. Your
total time billed should match the time blocks
documented on the anesthesia record.
DON’T USE DISCONTINUOUS FOR:


Relief issues
Broken medical direction, or when an
anesthesiologist must leave in the middle of a
case
Unusual Time Situations


Extended Care
Relief


The anesthesia provider with the longest time is
the provider who will bill for the services.
Example: Dr. A starts at 9:03 and Dr. B starts at
10 13 and
10:13
d stop
t ti
time iis 13
13:16,
16 D
Dr. B would
ld bill for
f
the entire time 9:03 - 13:16 as he was the doctor
with the longest time on the case.
14
Modifier Types

Physical status








Most insurance
P1= normal healthy patient = 0 units
P2 patient with mild systemic disease = 0 units
P3 = patient with severe systemic disease =1 unit
P4 = pt. w/severe systemic that is a constant threat to life = 2 units
P5 = a moribund pt who is not expected to survive without the
operation = 3 units
P6 = declared brain-dead pt whose organs are being removed for
donor purposes
Medicare

No additional units paid
Modifier Types (Cont)







Age = 99100 =1 unit
Emergency = 99140= 2 units
Hypotension = 99315 = 5 units
Hypothermia = 99116 = 5 units
Field avoidance = 2 units up to five base units total
((Mayy have to add a modifier like 22 for some
insurance companies)
Unusual position = 2 units up to five base
Medicare

Not paid
15
Modifiers (Cont)
Anesthesia Modifiers Used




AA – Anesthesia services performed by
anesthesiologist
QY – Medical direction of one CRNA by an
anesthesiologist
QK – Medical direction of two,
two three,
three or four
concurrent anesthesia procedures
AD – Medical supervision by a physician, more than
four concurrent anesthesia procedures
Modifier (Cont)
For Services by the CRNA



QX – CRNA service with medical direction by a physician
QZ – CRNA service without medical direction by a physician
MONITORED ANESTHESIA CARE (MAC)


G8 – MAC for deep complex, complicated or markedly invasive
surgical procedure
QS – Monitored anesthesia care services
USE G8 & QS MODIFERS IN ADDITION TO THE
ANESTHESIA MODIFIERS (EXAMPLE: AA QS G8)
YOU CAN ALSO APPEND A MODIFER G9 FOR PT WITH A HISTORY
OF SEVERE CARDIOPULMONARY CONDITION (THIS WOULD
JUSTIFY THE PRESENCE OF THE ANESTHESIOLOGIST IN A MAC
CASE THAT MIGHT NOT NORMALLY QUALIFY FOR COVERAGE.

16
Modifiers (Cont)




59 – Used when anesthesiologist does other procedure along
with
ith providing
idi anesthesia.
th i (i
(i.e. TEE (transesophageal
(t
h
l
echocardiography)
26 – As they do not own the equipment used
73 – Out patient procedure discontinued prior to anesthesia
administration. NOTE: Elective cancellation of a service
prior to administration of anesthesia should not be reported.
Physician reporting discontinued procedure see modifier 53
74 – Out patient procedure discontinued after the
administration of anesthesia. (Local, Regional Block or
General)
Patients Who Have Received Anesthesia Care Must
Receive Post-anesthesia Management


All patients who receive anesthesia care shall be
admitted to PACU or its equivalent except by
specific order of the anesthesiologist responsible for
the patient’s care.
A PATIENT TRANSPORTED TO THE PACU
SHALL BE ACCOMPANIED BY A MEMBER
OF THE ANESTHESIA CARE TEAM.
17
Upon Arrival in the PACU, the Patient
Shall be Re-evaluated
And a Verbal Report Provided to the Responsible
PACU Nurse by the Member of the Anesthesia Care
Team Who Accompanies the patient
The patient’s status on arrival in the PACU shall be
documented
Information concerning the pre and intra-operative
course shall be transmitted
The member of the anesthesia care team shall remain
in the PACU until the PACU nurse accepts
responsibility for the nursing care of the patient
Summary


Know what is beingg billed
Know your insurance companies and how
they want to be billed



Base Units
Time Units
Modifying Units
18
Anesthesia Resources





Anesthesia Crosswalk
ASA Relative Value Guide
CPT®- Level I
HCPCS – Level II
The Coding Institute: Anesthesia & Pain
Management Coding Alert
WEBSITES FOR ANESTHESIA




http://www.trailbalzerhealth.com/medicare.aspx
p
p
CMS Anesthesia Manual
www.ASAhq.org Crosswalk and RVG from the
American Society of Anesthesiologists
http://www.codinginstitute.com/spec_anesthesia.htm
l Anesthesia and Pain Management
g
Codingg Alert
http://www.anesthesia-decisions.com Anesthesia &
Pain Coder’s Pink Sheet From DecisionHealth
19
THANK YOU
I hope
p yyou have learned a little about the world
of anesthesia and how to bill for the
anesthesiologists’ services
QUESTIONS?
20